Endometriosis Surgery, State of the Art

Endometriosis Surgery, State of the Art
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Hans van der Slikke, MD, PhD: “It’s July of 2002 and we’re in Vienna at the ESHRE Conference. Next to me is Philippe Koninckx the famous Belgium surgeon and endometriosis specialist. Welcome, Philippe. We’re going to talk about treatment of endometriosis and especially about the state of the art of endometriosis surgery these days. What’s the modern treatment of endometriosis?”

Philippe Koninckx, MD: “I think endometriosis still is predominantly a surgical treatment. All alternatives which are coming, have at this moment still a long way to go. On the other hand, medical treatment at this moment is a second choice when surgery cannot be done or is not available. At this moment surgery is definitely the method of choice.”

Hans van der Slikke, MD, PhD: “Why are there such differences between hospitals in results and in efficacy?”

Philippe Koninckx, MD: “I think surgery is facing a lot of structural problems. First of all, we should look back ten years when we started with endoscopy. At that moment every one of us thought that everybody was going to catch up with this new modality of surgery. We gynecologists were the inventors of endoscopic surgery. When I around today, i.e. ten years later, I think we failed to a large extend to get across the message. Indeed there is a growing discrepancy between those who are doing very performing , very aggressive, and very complete resection, and what is done by most of the gynaecologists. On the other hand, when we onsider which kind of surgery is available today for most of the women, we must admit that advanced surgery is still not widely available.”

Hans van der Slikke, MD, PhD: “Why is this kind of surgery not available for them?”

Philippe Koninckx, MD: “We do have a real problem running the risk of becoming an old boys’ club. With this I want to stress that the “great names” in endoscopic surgery for endometriosis seven or eight years ago and today are still the same. There are few youngsters coming into the field, although I think it’s an absolute necessity that these get recruited and trained, in order to have a decent follow-up. I think the real problem we are facing is based upon three difficulties. First, there is not enough surgery available to let all gynecologists do surgery. If I would state that every gynecologist who does surgery should at least operate for one day a week this would imply that half of the gynecologists should stop to perform surgery. The problem is that, although this is well known, no authority, no group of gynecologists, and no association will ever find a solution or an agreement to decide who can and who cannot do this kind of surgery. The second difficulty is the absence of a simple standard of outcome. When you consider IVF treatment, the comparison of pregnancy rates is a simple endpoint. Surgery, on the contrary is so different with cases ranging from very little to very severe and very complicated surgery. Also the experience of surgeons is different and, most important the standards of outcome are ill defined being pregnancy rates and pain. What happened after the introduction of endoscopic surgery was everybody started to do some surgery with in the back of the mind the knowledge that if the surgery is not leading to a pregnancy, in vitro fertilization always remains an alternative. The third problem is cost. Sometimes people forget that a baby born after in vitro fertilization costs society between five and ten times more than any baby born after surgery. For this reason, if I would be Minister of Health I would not only regulate IVF, but I would certainly regulate surgery for infertility. Moreover I would increase the price of surgery four or five times, but ask for quality.”

Hans van der Slikke, MD, PhD: “Can you give some examples?”

Philippe Koninckx, MD: “Typical examples for this are deep endometriosis, cystic endometriosis, and hydrosalpinges. At this Congress during the precongress workshop, which we had on Sunday, there was a presentation on deep endometriosis with surgery still performed by open laparotomy. If you compare this with what many of of us are doing since a long time the discrepancy is obvious. I e.g. gave a drink in the department in 1995 to announce that I had done my last laparotomy in my life. The advantages of laparoscopy for the woman is clear, yet laparotomy is still very pevalent. Second example: cystic ovarian endometriosis. After resection of an endometriotic cyst performance in in vitro fertilization is quite good in several series. Yet after the meeting, several gynecologists came to me with the following question: “When I send somebody for surgery, afterwards it becomes very difficult to stimulate that ovary, what is the explanation?” Nobody knows with certainty what the explanation is but I would not be surprised if the explanation would be the following. If because of lack of sufficient experience, an endometriotic cyst larger than 6 cm is operated, the risk is real that the end result is the resection of half of the ovary; if in addition the second half is coagulated because of bleeding the end of the story is this ovary no longer responds. A third example is the hydrosalpinx. This is a typical example of how a discussion can be the wrong discussion. It’s very well known that the results of in vitro fertilization improve after removal of an hydrosalpinx. From this some people have concluded that you should remove all hydrosalpinges before in vitro fertilization. With this they forget that the first treatment of choice of thin-walled hydrosalpinges still is surgery, with provided a decent salpingoscopy, we have according to the reports pregnancy rates between 30% and 60%. The aim indeed is not to choose the method with the highest pregnancy rate; the aim ifor the woman to go home with a baby. The best chances for women to finally have a baby is to first do surgery, good surgery. In those who fail to become pregnant, and only then in vitro fertilization should be done.”

Hans van der Slikke, MD, PhD: “This is rather provocative, Philippe. If there’s no surgery or if surgery fails, what are the alternatives for endometriosis - that’s what we’re talking about now.”

Philippe Koninckx, MD: “We already commented about the treatments which are available at this moment like GnRH agonists and oral contraception. These treatments are very efficient for treating pelvic pain; I think they’re also very efficient long term, and many of these women remain pain free. When you consider the pipelines of medical treatment, as discussed on Sunday, with products such as aromatase inhibitors, blocking agents for angiogenesis, antiprogestins, and many others I think this is very exciting, since we will probably have really good products within - and this may be the disappointing point – five or ten years or longer.”

Hans van der Slikke, MD, PhD: “So for the women of today they have to wait?”

Philippe Koninckx, MD: “No, they have to find a good surgeon.”

Hans van der Slikke, MD, PhD: “Thank you very much.”